U.S. DOD Form dod-dd-137-5 CONTROL NUMBER DEPENDENCY STATEMENT INCAPACITATED CHILD OVER AGE 21 Form Approved OMB No. 0730-0014 Expires Sep 30, 2007 The public reporting burden for this collection of information is estimated to average 1.25 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0730-0014). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO YOUR LOCAL SERVING PERSONNEL/PAYROLL OFFICE. PRIVACY ACT STATEMENT AUTHORITY: Executive Order 9397, November 1943; 37 U.S.C. Chapter 7; 10 U.S.C. Chapter 55; and Department of Defense Financial Management Regulation (DoDFMR) 7000.14-R, Vol. 7A, Military Pay Policy and Procedures - Active Duty and Reserve Duty. PRINCIPAL PURPOSE(S): The information provided on this form will be used to determine the relationship and dependency of an individual on the military member, for entitlement of authorized benefits. ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. Section 552a(b) of the Privacy Act, as amended. It may also be disclosed outside of the Department of Defense to the Internal Revenue Service (IRS) for tax purposes, and the Department of Veterans Affairs (DOVA) regarding DOVA compensation. Other Federal, State, or local government agencies, which have identified a need to know, may obtain this information for the purpose(s) identified in the DoD Blanket Routine Uses as ppublished in the Federal Register. DISCLOSURE: Voluntary; however, failure to provide this information will result in a suspension of the dependent entitlement until the military member provides the required certification. INSTRUCTIONS The member must complete the form in its entirety, sign and date the form, and have it notarized. If the child resides alone or with someone other than the member, the member completes Items 1, 2, and 16, signs and dates the form, and the child or child's representative completes Items 3 through 15, signs and dates the form, and has it notarized. If the member is deceased, the child or child's representative completes the form in its entirety, signs and dates the form, and has it notarized. Information furnished must reflect the 12 months prior to member's death. Verification of income is required. NOTE: Answer all questions. If any question does not apply, write "NOT APPLICABLE" or "N/A" in that block. Use the Remarks section when required. Incomplete answers will delay final action on the application. 1. ENTITLEMENTS REQUESTED (X and complete as applicable) a. TYPE BAH b. FIRST APPLICATION? USIP CARD TRAVEL ALLOWANCE c. LAST APPLICATION WAS YES (If No, give date of last application) APPROVED NO (YYYYMMDD) DISAPPROVED 2. MEMBER INFORMATION a. NAME (Last, First, Middle Initial) b. SSN c. RANK d. STATUS (X and complete as applicable) ACTIVE DUTY NATIONAL GUARD ARMY NAVY DECEASED (Date of death) (YYYYMMDD) RETIRED RESERVE MARINE CORPS AIR FORCE OTHER (Specify) e. COMPLETE RESIDENCE ADDRESS (Street, Apartment Number, City, State, ZIP Code) f. COMPLETE MILITARY ADDRESS (Include assignment: squadron and base) g. TELEPHONE NUMBERS (Include DSN or Area Code) (1) WORK h. E-MAIL ADDRESS i. MARITAL STATUS (X one) (2) HOME SINGLE SEPARATED MARRIED DIVORCED WIDOWED 3. MEMBER'S CHILD a. NAME (Last, First, Middle Initial) b. SSN c. DATE OF BIRTH (YYYYMMDD) d. RELATIONSHIP TO MEMBER (X one) LEGITIMATE CHILD CHILD BORN OUT OF WEDLOCK e. COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code) ADOPTED CHILD STEPCHILD f. HAS CHILD EVER BEEN MARRIED? (If Yes, attach a copy of annulment decree, final divorce decree, or death certificate of child's spouse.) YES NO DD FORM 137-5, OCT 2004 PREVIOUS EDITION IS OBSOLETE. Page 1 of 5 Pages 4. CHILD'S OTHER PARENT(S) a. (1) NAME (Last, First, Middle Initial) b. (1) NAME (Last, First, Middle Initial) ((2) RELATIONSHIP TO CHILD ((2) RELATIONSHIP TO CHILD (3) COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code) (3) COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code) c. IS/ARE OTHER PARENT(S) IN ANY BRANCH OF SERVICE, INCLUDING RESERVE OR NATIONAL GUARD (X one) (If Yes, show rank, name, SSN, and military address.) YES d. DOES OTHER PARENT CLAIM CHILD FOR BASIC ALLOWANCE FOR HOUSING (BAH), TRAVEL ALLOWANCE, OR USIP CARD (X one) (If Yes, explain.) NO YES NO 5. CHILD'S RESIDENCE a. TYPE OF RESIDENCE (X and complete as applicable) HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship) HOME OR APARTMENT OF OTHER PARENT HOME OR APARTMENT OF MEMBER HOME OR APARTMENT OF CHILD HOSPITAL OR INSTITUTION HOME OR APARTMENT OF FORMER SPOUSE OF MEMBER OTHER (Explain) STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY b. OWNER OF RESIDENCE (1) NAME (Last, First, Middle Initial) (2) ADDRESS (Street, Apartment Number, City, State, ZIP Code) c. IS RESIDENCE SUBSIDIZED HOUSING? d. DATE CHILD STARTED LIVING AT CURRENT ADDRESS (YYYYMMDD) YES NO 6. IF CHILD IS IN HOSPITAL OR INSTITUTION If child is in a hospital or institution, all of the following information must be furnished. Obtain this information from the hospital or institution. a. DATE CHILD ENTERED HOSPITAL/INSTITUTION (YYYYMMDD) b. ANTICIPATED DATE OF DISCHARGE (If known) c. WILL CHILD RETURN TO MEMBER'S HOME AFTER DISCHARGE? (If "NO," explain where child will reside) YES NO d. CHILD'S EXPENSES IN HOSPITAL OR INSTITUTION ITEM PRESENT MONTHLY EXPENSE TOTAL EXPENSE FOR PAST 12 MONTHS ITEM (1) ROOM (8) EDUCATION (2) FOOD (9) TRANSPORTATION (3) REHABILITATION CLASSES OR SERVICES PRESENT MONTHLY EXPENSE TOTAL EXPENSE FOR PAST 12 MONTHS (10) PERSONAL INSURANCE (Specify) (4) SPECIALIZED EQUIPMENT (11) OTHER (Specify) (5) MEDICAL CARE (6) CLOTHING (7) LAUNDRY/DRY CLEANING DD FORM 137-5, OCT 2004 Page 2 of 5 Pages 6. IF CHILD IS IN HOSPITAL OR INSTITUTION (Continued) e. CHILD'S EXPENSES IN HOSPITAL OR INSTITUTION ARE PAID BY: SOURCE (1) U S I P C A R D PRESENT MONTHLY EXPENSE TOTAL EXPENSE FOR PAST 12 MONTHS PRESENT MONTHLY EXPENSE SOURCE (a) CIVILIAN MEDICAL TREATMENT FACILITY (CHAMPUS) (3) STATE OR LOCAL AGENCY (Give name and address in Remarks section) (b) MILITARY MEDICAL TREATMENT FACILITY (4) MEMBER TOTAL EXPENSE FOR PAST 12 MONTHS (5) OTHER (Explain and give name and address in Remarks section) (2) PRIVATE INSURANCE (Give name and address in Remarks section) 7. PERSONS LIVING IN HOUSEHOLD WITH CHILD When child resides in a hospital or institution and Item 6 is completed, do not complete this item. List all persons who live in the household, including claimed child. If employed, show hours per week worked. Continue in Remarks if more space is needed. a. NAME (Last, First, Middle Initial) b. RELATIONSHIP TO CHILD c. AGE d. MARRIED (X) YES NO e. EMPLOYED HOURS PER WEEK NO (X) 8. HOUSEHOLD EXPENSES When child resides in a hospital or institution and Item 6 is completed, do not complete this item. List the household expenses for all persons living in the home. If expense was one-time only, such as purchase of a new chair, do not show this as a monthly expense; list it as an expense for the past 12 months. If child resides in the member's household or in a dwelling owned by the member, use Fair Rental Value (FRV) for dwelling. If child does not reside in member's household or in a dwelling owned by member, list actual mortgage, rent, or FRV if dwelling is mortgage-free. If FRV is used, give a brief explanation of how Fair Rental Value was obtained using the Remarks section. FAIR RENTAL VALUE (FRV): FRV is a single monthly sum for the entire dwelling where the child lives. This sum is an amount the owner can reasonably expect to receive from a stranger to rent the dwelling. FRV will not include food, utilities, furniture, and home repairs, which are listed separately. ITEM (1) PRESENT MONTHLY EXPENSE (2) TOTAL EXPENSE FOR PAST 12 MONTHS a. (X one) ITEM (1) PRESENT MONTHLY EXPENSE (2) TOTAL EXPENSE FOR PAST 12 MONTHS d. FURNITURE AND APPLIANCES RENT FRV MORTGAGE (Specify amount of tax and insurance if applicable) e. REPAIRS ON HOME TAX INSURANCE b. FOOD f. OTHER (Itemize in Remarks section) c. UTILITIES (Heat, power, water, and telephone) 9. CHILD'S PERSONAL EXPENSES When child resides in a hospital or institution and Item 6 is completed, do not complete this item. List all of the child's personal expenses regardless of who is paying for them. ITEM (1) PRESENT MONTHLY EXPENSE a. CLOTHING b. LAUNDRY AND DRY CLEANING c. MEDICAL (Do not include expenses paid by insurance, welfare, or Medicare) d. VALUE OF USIP CARD (Verification of amount is required) (2) TOTAL EXPENSE FOR PAST 12 MONTHS ITEM (1) PRESENT MONTHLY EXPENSE (2) TOTAL EXPENSE FOR PAST 12 MONTHS g. PRIVATE AUTO PAYMENTS (If auto is registered in child's name) h. MONTHLY TRANSPORTATION PAYMENTS (Specify type) i. SCHOOL EXPENSES j. OTHER (Specify) e. PERSONAL INSURANCE (Specify) f. PERSONAL TAXES (Specify) DD FORM 137-5, OCT 2004 Page 3 of 5 Pages